To be known only by your initials means you’ve reached The Big Time: JC, FDR, JFK…AJW. And so it goes with injuries: if it is known only by its initials, you know its impact is widespread and deeply-rooted.

PF – Every long-term runner knows it. Each fears it.

Nothing ruins a perfectly good runner like plantar fasciitis, the dreaded snake bite of the heel and arch of the foot; in essence, nasty foot pain that prevents us from running. Once it sets in, is one of the most menacing and stubborn conditions.

Ultrarunners seem particularly prone to heel and arch pain. Both up and downhill running stresses the foot: the ups stressing the soft tissues of the plantar arch, and the downhills providing ample pounding for the joints.

It’s okay to call your foot and heel pain plantar fasciitis – just like that Coke at the aid station that might be Pepsi or RC Cola. But be sure that you – and your doctor, PT, chiropractor, LMT or other healthcare helpers – are aware of all of the different sources of foot pain. Awareness is the first step in comprehensive treatment and fast recovery from the dreaded “PF” and its brethren.

Plantar Fasciitis, Defined

The plantar fascia is the thick connective tissue that runs from the base of the heel, to the bones of the forefoot. Collectively, with intrinsic foot and ankle muscles, it supports the arch of the foot and helps transfer energy from the forefoot to the rearfoot and ankle, and up the leg.

By definition, in a truly literal sense, fasciitis is an active inflammation of that tissue.

But is foot and heel pain always plantar fasciitis? In a clinical sense, one can only have fasciitis if an active inflammatory event is occurring. Since inflammation only lasts twenty days, indeed, not everyone with persistent foot pain truly has fasciitis.

Not all tissue paper is Kleenex. Not all lip balm is Chapstick. And so it goes, not all heel and arch pain is plantar fasciitis. But as Shakespeare once said, “Is foot pain by any other name, any less excruciating?”

However, to label all foot pain as plantar fasciitis possibly limits one’s ability to quickly and effectively recover from it. Below are some other, equally common causes of foot pain.

Foot Pain: Differential Diagnosis

There are a many possible sources of persistent heel and arch pain. Here are the most common I see, clinically:

Soft tissue sprains and strains. There are several major muscles, tendons and ligaments that span from the heel and ankle to the toes. Besides the plantar fascia, there are several flexor tendons – of muscles originating on the lower leg – that course their way into the foot. Any number of these tissues can become strained under the load of road and trail running. A review of the Rules of Tissue Loading explains how a plantar surface tissue can become irritated.

However, since soft tissue tends to heal quickly given proper treatment, these causes tend to heal rapidly. Those with persistent heel and arch pain – who see me and other medical folks after weeks, months, and even years of pain – tend to have a pain generator of different origins:

Joint Pain. There are over two dozen joints in the foot and ankle complex. With the extreme stress of ultra trail running, these joints could become stiff, irritated, or both.

Joints – articulating surfaces of two bones – require but two things to be happy:

Full range of motion

Symmetrical, equal loading of surfaces

Seems simple, but running hard and long on uneven surfaces can strip a joint of those two things.

Range of motion loss. Joints get the bulk of their nutrition from range of motion. The vast majority of joints in the body are synovial: two bones surrounded by a leathery capsule filled with fluid. The cartilage surfaces receive very little blood flow. In order to receive nutrition, the joint must “lubricate” itself with the fluid of the joint, absorbing nutrients from the fluid along its surface – via regular, full range of motion.

When joints stop moving through their full range, elements of cartilage do not get this nutrition. The cartilage dries up. And it is replaced with bone. This, by definition is osteoarthritis. Preceding that, is pain.

Asymmetrical loading. Joints have the ability to move – sometimes small amounts in one plane; sometimes substantial amounts in many directions. But when running, joint surfaces are designed to be loaded so that the entire surface of one bone impacts flush against the other. This promotes maximum stability; it also ensures that cartilage receives a steady dose of hydration and nutrients.

Asymmetrical loading occurs as the result of abnormal running surfaces – uneven, rocky trails, or a cambered/slanted road – or with inefficient running mechanics.

And when a joint becomes unhappy, it causes pain. Typically, a painful joint will hurt at its precise point of irritation. But joints of the ankle and foot will frequently refer pain to adjacent areas, out the sides or beneath the point of irritation, at times mimicking soft tissue pain.

How can you tell if you have a soft tissue or joint issue? Below are some comparisons:

Soft Tissue Pain Characteristics

Succinct, reproducible, palpable tissue pain. Can you find the one spot that is tender?

Pain with active use: when you do a toe curl or use the muscle (absent weightbearing), does it hurt?

Pain with passive stretch: is pain produced when you bend back your foot and toes? (again, without weighbearing)

Pain with resisted testing: when flexing your foot and toes, is there pain?

Joint Pain Characteristics

Dull, diffuse pain: no discernible “tender spot”. Rather, it hops around and you can’t put your finger on it.

Pain with weightbearing through the joint.

Pain is worst in the morning, after prolonged weightbearing, and/or after resting, then bearing weight through the joint.

The three usual joint suspects – the talocrural, the subtalar and the talonavicular – can all become painful and mimic plantar fascial pain. Each joint lies on the medial plantar surface of the foot, and each is prone to stiffness and asymmetrical loading during running.

Medial view of a foot and ankle model, identifying three common problems joints for runners.

Above shows a medial view of the foot, showing three main joints of the foot. The talus plays a role in all three: it is the go-between from the foot and leg bones.

From above, it forms the talocrural joint. The main motion for this joint is “up and down” – it allows the toe up/toe down action that occurs in the run stride.

This joint is prime to get stiff, especially with repetitive downhill running: rather than smoothly sliding and gliding, hard downhill trail running can cause jamming forces of the talus into the tib-fib. And when this joint gets stiff, it can refer pain in any direction around the talus – front or back of the ankle (mimicking both anterior tib tendonitis and Achilles tendonitis, respectively), or it can spit pain out the side – namely the medial ankle and arch.

Between the talus and the calcaneus – or heel bone – is the subtalar joint. It is designed to move in several axes, but its primary axis of motion is medial to lateral. This joint is of little consequence to the healthy, normal runner: minor motions occur depending on the gait cycle. However, deviations or inefficiencies – namely in the foot strike pattern – can cause significant pain emanating from the subtalar joint. Excessive lateral foot strike can cause stressful joint compression to the medial aspect of the joint – mimicking plantar fascial pain!

Lastly is the talonavicular joint. This joint is the primary conduit from the fore and midfoot to the ankle and leg. The navicular bone is the “keystone” of the arch. Stiffness or irritation here can also cause significant arch pain.

The following are some illustrations of how mechanical forces can cause joint and soft tissue pain:

Over-pronation, as shown with shoe and joint model.

Medial view of a collapsed arch.

Excessive medial foot landing leads to over-stressing of the medial arch, or “arch collapse.” This stresses all tissues of the plantar surface and is the primary etiology of true plantar fascial pain.

Excessive lateral foot strike/supination, as shown with a shoe and joint model.

Excessive lateral striking significantly compresses the medial joint surface of the subtalar joint. This compression accounts for a large percentage of non-plantar fascial foot pain cases. It refers pain at its site, but also farther down into the arch and along the heel bone.

Too much lateral strike can also cause plantar fascial torqueing: the heel rotating to the right (in the above picture), but the forefoot rotates to the left as it contacts the ground – adding a twisting force to the fascia.

Nerve pain. Perhaps the most unrecognized and overlooked factor in heel and foot pain is nerve pain. The peripheral nerves of the ankle and foot originate in the brain, course through the spine, exit the low back and pelvis, and must course – fluidly – through the soft tissues of the entire leg.

Repetitive impact forces from running – often combined with compromised spine posture from running all day (or, in our normal lives, sitting) – can cause these nerves to develop “hitches.” This is a concept called nerve tension.

Nerve tension accumulates in the spine and legs with age, injury history, and running volume. When nerves lose mobility, they begin to create pain – often very similar to soft tissue or joint pain, including plantar foot pain.

And because the same repetitive or excessive impact forces that create joint and soft tissue pain also create nerve tension, it is very common for a runner to present with both joint/soft tissue and nerve pain overlay at the same time.

Almost every runner (and most other folks) has some degree of nerve tension. Here’s a test:

Sit with your back against a chair, head and shoulders upright. Extend your knees straight, with toes up. Note the degree of “stretch” in the back of your legs. Then, slump your head and shoulders. Any increase in stretch sensation is nerve tension from tensing the nerve at the head and neck.

Nerve Pain Characteristics

Pain at rest – the hallmark sign of nerve pain overlay: do you have any symptoms in your foot when at rest, namely sitting (specifically, with prolonged sitting, long after you’ve stood on it)?

Very often, a runner who applies soft tissue or joint treatment concepts will get partially better, but fail to fully recover because they fail to address the nerve tension component.

Runners and clinicians, alike, need to recognize the existence of nerve tension and treat it concurrent with any soft tissue or joint irritation.

Treatment Approaches

Please discuss any of the following treatment approaches with your doctor, physical therapist, or chiropractor before performing.

Soft tissue

These are straightforward because everyone who [thinks they have] PF does them:

Rest, ice, soft tissue mobilization, stretch, strengthen.

Real, actual soft tissue plantar pain will heal rapidly, given correct doses of the treatments above. Those who do not respond to that approach likely have a joint or nerve issue.

Joint pain

The two treatment approaches to joint pain in the foot include full restoration of joint range of motion and symmetrical loading.

Range of motion restoration

Ankle dorsiflexion. Normal ankle dorsiflexion is about 20-30 degrees beyond a 90-degree bend at the ankle. If you cannot stretch this far – or if you have symptoms in front, or anywhere around the ankle joint – your symptoms might be due to stiffness there. To mobilize a stiff talocrural joint, try the following:

Perform a standard calf stretch, with a few minor adjustments: be sure your stretch foot is perfectly straight ahead. Keep the foot flat, lean forward with a straight knee until full tension. Then, slowly bend the knee as much as possible without allowing the heel to rise. Slowly oscillate between bent and straight knee. This mobilizes the tibia and fibula over the talus, restoring motion to this joint.

Wall ankle stretch – straight knee.

Wall ankle stretch: bent knee. Keep the heel as flat as possible.

Subtalar inversion and eversion. A normal heel bone should be able to “wiggle” about 10-20 degrees side to side. To self-test, cross your ankle over opposite knee. Grasping hold of your ankle with one hand, drive firmly downward with your opposite hand on the inside of your heel bone. Can you move it, at all? If not – and you have heel and arch pain on the bottom/medial side of your foot, your symptoms may be coming from stiff subtalar joint.

To self-mobilize, perform the maneuver described above with firm, slow, on and off downward pressure. The degree of motion will be slight, but the potential for pain relief is substantial when motion is restored here.

The author applying a straight-downward pressure to the heel bone, stabilizing at the ankle. A normal heel will “wiggle” a few millimeters in both up and down directions.

Midfoot arch. A normal midfoot will have some degree of give – both to the hands, and when standing on it. In standing, a normally mobile foot should “sink” a few millimeters to the floor.

Shoe orthotics are intended for those who are hypermobile in their arch: their arch joints are excessively flexible, and the arch “collapses” (typically defined as one centimeter or more) in weightbearing.

However, far more often than not, runners have hypomobile arches – they simply don’t move enough. These folks typically respond poorly to orthotics (often with no improvement, and sometimes they worsen pain).

A hypomobile, stiff arch will benefit from self-mobilization. If you have symptoms that originate farther down the foot, near the apex of the arch – and your foot lacks any give in standing – try the following mobilization:

Stand with stiff foot down. Place your opposite heel directly on top of the stiffest area – typically the navicular bone, which lies directly in front of the tib-fib complex. Gently, then progressive bear down with substantial weight onto the navicular. This may seem scary – test it first. A stiff navicular will give very little, even with full pressure. Pain usually comes from skin compression. “Stomp” on and off 10-20 times. Perform before and after running, and/or in the morning, when stiff joints tend to be stiffest.

The author, performing a mid-foot self-mobilization in standing. Try with soft-heeled shoes on, if too sore with direct skin contact.

Joint Loading Factors

Loading the joint equally is vital to joint happiness. Orthotics can be helpful for those with hypermobile feet, as they can prevent arch collapse. They are also helpful for slower runners with shorter stride lengths. A short stride tends to include excessive vertical forces (up and down motion). This vertical loading bears down on the medial arch – beyond the capability of muscles, tendons, and the plantar fascia to support it. An orthotic can aid in sustaining the arch. But ultimately, an efficient stride that emphasizes normal hip mobility with greater forward momentum is most important in preventing arch collapse.

Other important factors for symmetrical, low-stress loading include the position and angle of foot strike. The foot should always land as close to directly beneath one’s center of mass as possible. A foot that strikes in front, tends to strike:

On the heel

On the outside edge of the foot (heel or midfoot)

On the mid or forefoot, laterally-biased.

A heel strike creates considerable stiffness through the talocrural and subtalar joints. A lateral strike might cause asymmetrical loading of the subtalar joint, and/or a twisting, torqueing force through the midfoot and plantar fascia (see photo above). A midfoot or forefoot strike – significantly ahead of the body – will stress out those joints or strain the plantar fascia.

The most simple, sustainable and important way to correct a foot strike issue is addressing it proximally:

Proper forward trunk engagement

Moving the hips such that the foot is “pulled” beneath the body

After ensuring proper foot placement beneath the trunk, shoot for a whole-foot strike, where all elements of the foot are absorbing and sharing impact forces.

Nerve pain

To treat nerve tension, refer to the test above, except make one slight adjustment:

Sit in a chair, slumped forward. Slowly extend the affected leg with toes up. As the foot and lower leg rise, slowly extend your head at the same speed. The degree of stretch should be significantly less – but still present. Hold one second, then slowly lower. This is referred to as a “nerve floss” exercise: the head gives the nerve slack that is taken by the foot, and vice versa. Repeat ten to twenty times, and perform three to four times a day, especially before and after running. Here is a video link for the exercise.

Joe Uhan is a physical therapist, coach and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 18 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level I and II Certified Coach. Joe ran his first ultra at Autumn Leaves 50/50 in October 2010, was the bronze medalist at the 2012 USATF 100K Trail Championships, and finished M9 at the 2012 Western States 100. Joe works at Eugene Physical Therapy in Eugene, Oregon, and offers online coaching and gait analysis at joeuhan.blogspot.com.All posts by Joe Uhan

Comments

6417137 Responseshttp%3A%2F%2Fwww.irunfar.com%2F2012%2F10%2Fis-your-plantar-fasciitis-plantar-fasciitis-and-what-to-do-about-it.htmlWhat+If+Your+Heel+Pain+Isn%27t+Plantar+Fasciitis+and+What+to+Do+About+It2012-10-09+10%3A00%3A49Joe+Uhanhttp%3A%2F%2Fwww.irunfar.com%2F%3Fp%3D6417 to “What If Your Heel Pain Isn’t Plantar Fasciitis and What to Do About It”

I have suffered PF in my right foot a few years back whilst trying to move up from a marathon runner to ultra runner (increased mileage too quick). I took a month off, it went away. Then late last year I got a dull pain in the left foot. I ignored it and kept running. I assumed it was PF. All the symptoms were text book but the thing is – it always started to hurt about 15km into a run. I got a second opinion from a podiatrist who sent me for an ultrasound and Xrays and his opinion was that I had done some damage to the PF in the past and had small nodules on the PF as a result. Every time I ran over 15km, I got a bit sloppy with my form and started to roll my foot into my shoe therefore causing the pain. I was dubious about that explanation – ignored him – kept training and ended up with a stress fracture.

Since returning to the sport, I now have steady base of 50-70 miles per week. I do a marathon or ultra most months. The last three months I've been doing a lot more hill work and bam! The pain has come back in the left foot.

My osteopath thought it was PF and so did I except same as last time – I get pain about 15km into my run. This is making it really hard to do any long runs.

I really can't afford rest as I have a couple of big races coming up.

Do you think it could still be PF even though I'm getting pain DURING activity?

I have been suffering from heel pain on weight bearing, for a couple of years, and have been treated for PF.

I have had Orthotics, Physio, exercises, & cortizone injections. The first injection worked for three months and the pain came back worse that ever, the second one last November did not work.

In January last I had a MRI scan, result in brief – "6mm osteochondral lesion within the posterior aspect of tibiotalar joint, with minimal oedema, likely chronic. Trace ankle effusion. Plantar Fascia appears normal"

I met with an orthopaedic specialist who felt that the MRI result was not significant enough to be causing the discomfort. But is to consult with Neurophysiology Department and get back to me.

At the moment I feel I am getting nowhere.

I am 51 years old and I am not an athlete

I can send you a copy of the scan if required or the radiological report.

Thanks for the post! Though I definitely CANNOT diagnose or treat anything in this forum, your "defect" is suggestive of a gait (walking and/or running) issue where you're loading asymmetrically – in other words, how you're landing on that foot is not "equal", thus causing that defect.

Is the defect causing pain? No one can say (just as 50% of all people with ZERO back pain will have a bulging disc on MRI). But, you do have pain.

Find someone to take a good, hard, comprehensive look at how you walk and/or run. Make it equal, then slowly/progressively load!

i battled pf for awhile over a year ago, and now have a new heel pain that hurts on the back/sides of my heel… like if you were to pinch the sides of my heel and squeeze, it hurts! this is *not* plantar fasciitis is it? i can't find what it might be from your article and don't really know where else to look as everything seems to call heel pain plantar fasciitis. i think it's due to a new shoe. didn't hurt during my last run in them (of 8 miles, after several shorter runs in the same shoe, 25 total shoe miles), but hurt to walk that night and the next day (which was yesterday) and i still can't walk normally now! i supinate if that helps.

Great article. I found it searching for "heel pain from running". My experience is a little different. 3 years ago I had a subtalar implant in both feet (in the sinus tarsi cavity) to correct flat feet. Things have been great (except for an occasional twinge in my left foot if I'm on an uneven surface) However I've started a very slow "Couch to 5K" running program. The first day I ran a total of 8 minutes in a 30 minute program. The next day there was significant pain in my right foot when I put weight on it. It doesn't hurt any other time. I can't replicate the pain when pressing only when walking.

THe doctor who did the surgery doesn't know why as his other patients who run haven't had the same issues. He's also in LA and I now live in London so it's not like I can just pop in for him to check!!! I'm thinking it has "something" to do with the implant although I would expect the other foot to hurt as well.

Thanks for the in-depth article! My 10 year old son who is very active (soccer, 3days a week, Roller hockey, tennis, etc.etc) is currently and has had in the past very tender spots on the inside and outside of his heal bone. There is no acute pain on the arch or base of the heel strictly on the sides on a very small area. His soccer cleats and shoes all have good support. We have replaced the soccer insole with Super Feet and have bought more expensive running shoes for daily use and support. Wondering if you have any treatment suggestions and perhaps a diagnosis.

With a procedure like a subtalar implant, the playbook goes out the window – you have new (and sensitive) anatomy! With a change like that, it's doubly important to have excellent strength/range of motion AND efficient run mechanics.

My advice is to see a professional with a lot of experience in running gait – make sure you're efficient as can be, then be very patient!

I would have a PT, chiropractor or osteopath look at the mobility of your rear foot (ankle, heelbone, etc). Make sure it's moving the way it should. The area where you describe symptoms is a prime area of referral for a stiff heel bone. But be sure to have it looked at, as it could be a muscle, tendon or even nerve issue, as well! Good luck.

Thank you so much for your reply. I wanted to give you an update on my progress.
I took inboard what you said, did some cutting back and variation of my activities and variation of where I was doing my activities.
I completed a second run I had already entered that was only 5.5km the week after my post to u. The night before I got some ITB pain predominately in my right leg. Fortunately a friend who is a very good runner helped me and we went and got a foam roller and sorted that out very quickly. But again as I hadn't run that week it continued to point out to me just how wrong everything was going.
We have a store here about an hour and a half from where I live called Active feet where the sales assistance are either qualified or final year podiatrist and they video u to see gate etc and then recommend shoes.
When they watched me bare foot yes I roll laterally but not so bad, get me into a jog it just gets worse and worse. interestingly it was my right ankle that appeared most unstable. 3 style of shoes later we achieved stability. Add In gel heel I had been wearing in my shoes just to cushion impact and they felt great. In comparison to my previous fitted shoes by a specialist they had easily 3x the lateral support.
Wore the shoes for the rest of the day and where I had started with ITP pain, I had non.
Went for a jog later in the week felt better again, left calf not so tight.
I couldn't tell u every response in the weeks following, but I can tell u I've only put my old runners (which were new) on for one walk since then.
Because i was stubborn and as part of my weight loss journey i needed to complete it, I progressed up and did do my 10km run. Legs pretty good after no need for a massage which is so different to back in March but I did suffer a fair amount of heel pain after I cooled down. I went and saw my Dr and said I need help I don't want to stop running but needed more help and we weren't getting to a resolution. I asked if I could get an X-ray, as I thought that previous blow a few months back may have caused a fracture. Ps I had X-ray 2 years ago at start of first PF issue which showed nothing.
This time the X-ray showed a big heel spur. The doctor put me on an anti inflammatory immediately and has booked me for a cortisone injection in a few weeks. He said we will give that a go and if that's not working he recommends surgery as from our history discussed I have already progressively worked my way threw the other management options which haven't worked.
Well after just 6 days on the tablets the heel pain has dramatically reduced. I had my final pre booked run on two days ago which was 13km which again mentally I needed to get over and do and despite having been in bed all week with a cold (so not even walking in the lead up) I got up and did. It took me 1:42 which was only 2 minutes behind my goal time. More amazingly though I feel great. I just got out of bed bare foot 1 day later which would normally hurt even without running and my foot feels great. I have a bit of thigh pain but it was a long run with hills it's expected, but calf fine, ITP fine, heel never better.
When the dr gave me the action plan I was skeptical that the injection would do anything, but given the tablets have done so much already I am hopeful.
My next planned run is in a month and its 10km. I won't do much running between now and then as I know mentally and physically I can do it and will be doing the majority of my work on an exercise bike and gym equipment giving my entire body a workout.
Hopefully that will give my foot recovery time and the injection a chance to work. I am more hopeful than I have been that a plan is coming together to help me manage and resolve into the future.
Certainly the new runners after having my gait reviewed has made a huge difference to my leg issues and feet and now the Dr's plan seems to also be working.
I am young, after being thin all my life and putting on to much weight over the last 5 years I have lost 14kg and have at least another 10 to go but if non of this works to keep me running I do know that I want to have this resolved for my future mobility.
I wanted to say thank you for your advise it made me think everything through and whilst I took a lot of your advise I also knew in these couple of months I needed to modify what I did do I could still achieve my short term goals that were mentally so important for me in achieving my long term weight loss.
My husband who has been overweight since being a teenager has become inspired by me and has now lost almost 10kg himself. He said he has never been able to run, but after coming out on his bike one day when I went for a run, he realised just how far I had come and how far behind he was. He started running on the treadmill and has worked his way up to a regular 5km with a weekly 10km and is going to do his first run with me next month. He has got the bug and as a family and attending my last 2 runs is seeing what I have got from the experience and our goal is to do 1 run a month to help keep us motivated and active, the kids are also itching to do their first run at some point.
So fingers crossed everything comes together for me and my foot and we get to achieve our monthly goal.

I was told that I have PF but I am really beginning to question this since nothing seems to be helping the stiffness and pain seems to be getting worse i can pinpoint a tender spot it is on the inside edge of my heel just as it starts to curve around by the arch but i am finding that all around the back of the heel is becoming painful and very stiff running up the cord at the back of my foot / ankle cannot weight bear when i first get up and extremely painful after sitting for a short period i am not a runner but I am on my feet 10 hrs a day in steel toe work boots got orthodics but still cant seem to get them correct so we are working on that still this pain has been going on for 7 months and is only getting worse not better i am doing heat cold stretches have tried anti- inflammatories nothing is working

Hi there. I have read your article and was going through the comments, and I have a similar problem as Nicholas who posted here recently. Please I don't know what to do, I have experienced pain in the arch of my left foot only for the last year. The more I am on my feet the more it hurts. The pain is hardly noticeable or not there at all when my foot is resting for long periods of time. It feels stiff in the morning when I wake up and I usually stretch my foot and leg for about 10 minutes before I get out of bed. The pain gets worse as the day goes on, significantly worse if I am walking a lot at work and such. The pain begins just in front of the bottom of my heel where the arch begins and radiates to the rest of the arch. Running is hardly even an option for me as the pain becomes too unbearable. I usually ice the painful area at night or sometimes before work and then stretch my foot afterwards. This gives me short term relief but I haven't gone a day without some form of pain in the last year.

I have had pain in my feet before a few years ago. I visited a podiatrist and was given orthotics but they did not help. The problem went away by itself but it came back two years later and has lasted longer than ever now. I am on my feet much more now than I was back then.

When I stretch my feet I can feel a 'clicking' in my left foot around the middle but not in my right. Could this be the talonavicular joint? I think my feet have some over pronation as well but like I said only my left foot experiences pain. My right foot is perfectly fine. I am going to see a professional this summer when I can but honestly I dont have high hopes. This is seriously ruining my life. I am a 23 year old male, quite tall (6'4) and about 215 lbs. Please share any advice you might have for me. Thank you.

Hi there. I have read your article and was going through the comments, and I have a similar problem as Nicholas who posted here recently. Please I don't know what to do, I have experienced pain in the arch of my left foot only for the last year. The more I am on my feet the more it hurts. The pain is hardly noticeable or not there at all when my foot is resting for long periods of time. It feels stiff in the morning when I wake up and I usually stretch my foot and leg for about 10 minutes before I get out of bed. The pain gets worse as the day goes on, significantly worse if I am walking a lot at work and such. The pain begins just in front of the bottom of my heel where the arch begins and radiates to the rest of the arch. Running is hardly even an option for me as the pain becomes too unbearable. I usually ice the painful area at night or sometimes before work and then stretch my foot afterwards. This gives me short term relief but I haven't gone a day without some form of pain in the last year.

I have had pain in my feet before a few years ago. I visited a podiatrist and was given orthotics but they did not help. The problem went away by itself but it came back two years later and has lasted longer than ever now. I am on my feet much more now than I was back then.

When I stretch my feet I can feel a 'clicking' in my left foot around the middle but not in my right. Could this be the talonavicular joint? I think my feet have some over pronation as well but like I said only my left foot experiences pain. My right foot is perfectly fine. I am going to see a professional this summer when I can but honestly I dont have high hopes. This is seriously ruining my life. I am a 23 year old male, quite tall (6'4) and about 215 lbs. Please share any advice you might have for me. Thank you.

With *chronic pain* – defined currently as any injury/pain that persists >3-6 months – requires a comprehensive approach:

1.) PAIN CONTROL. Your pain is current out of control. What that means is, your foot is trying to heal, and forces in your daily life ("walking a lot at work"…) are exceeding the healing and tissue tolerance of your foot.

Imagine a cut on your hand: it will scab over, and gradually close. But what happens if, after a day of healing, you rub on it for 10 seconds? Doing so on your uncut hand would be no problem (in fact, maybe you could rub hard for 2 minutes without as much as mild redness). But on a healing cut, 10 seconds re-opens the cut. And you start all over.

You must get pain under control: do only so much standing/walking so that you *feel better tomorrow*.

You need a professional to help you achieve pain control. All other elements – Mechanical, Neuromuscular, Motor Control – are secondary and useless without pain control.

Just wanted to share a success story of battling with PF. Last year I developed a nasty case of PF, due to overuse and switching to flat shoes while overusing. I was waking up every morning, dreading that first step, but kept running thinking it'd work itself out. Finally, I'd had enough and stopped running. I switched to a more supportive shoe, Mountain Masochists, and wore these all the time. I didn't run for over 3 months but did some hiking, climbing and took up swimming (including pool running). Daily, I did PF stretches and iced, usually 2-3 times a day. I also did self massage with a tennis ball and foam roller. I would've gotten more professional massages if I could've afforded them but only had a couple. I tried the sock that stretches the calf at night. I hated it. It would waked me up at night or I would take it off in my sleep. A new element I tried was acupuncture. I received treatments 2-3 times a week for 5 weeks. A week after I finished treatments, I woke up with absolutely no pain or stiffness. I then started to run again, building up really slowly and still wearing the masochists exclusively.

I have been free of PF for 6 months and just finished the Jemez Mtn 50k with no pain and feeling the best I've ever felt. The hills have caused a little bit of Achilles tendonitis but now I know the signs of when to stop and rest. I still stick with the Mountain Masochists for hard and long runs. I know they work so I don't want to chance injury by changing up shoes too much.

I hope I can keep PF away for good. Good luck to anyone battling this nasty injury.

Hi I am a netballer and I train quite regularly for about 3 years already. About three months ago, I started developing pain on my heel which was only felt when I took the first step in the morning. I self-diagnosed it as PF and ice it after every training. But now, the pain has gotten worse and I feel it whenever I try to run or when I stretch the area alittle bit. The pain lies only on the right side of my left foot, between my ankle and heel but slightly towards the lower part. Is this PF? I am not too sure whether to visit the doctor since I reckon that they would tell me to ice and stretch it, when I already am. Hopefully, you can help me with this problem! Thank you so much! :)

For those with persistent foot pain, I have to encounter one that did NOT have a significant "walking problem" or "running problem": in other words, have significant inefficiencies (read: over-stressing habits) with how they run and/or walk.

That said, you need to find someone that can take a good look at how you run/walk, and make adjustments so as to reduce the stress going through your foot/heel.

This is something I offer on my personal website, but you would be best served by finding a skilled physio in your area to work with.

I had acupuncture on it for 4 weeks after finding another article on it regarding anatomy trains and the calf.

I approached my physio with this in mind. She found nerve tension with some reflex tests and went to work. She also provided the 'chair / nerve floss' exercise plus some others.

6 weeks later i was slowly returning to running.

Until now, it's been fine , but a few weeks ago I done a 13 miler more on my fore-foot.

I'm trying to move further forward with my foot strike as I get faster.

It seems this has upset the PF again. Straight away I have moved XT for the time being.

I made the mistake last time of trying to run through it. lol!

Seeing this article especially the lateral/supination footstrike part and how it effects the PF has definitely made me think this is what has happened.

I've been performing the nerve tension exercises and already can feel an improvement. I Will wait to see how these effect it over the next week or so before deciding whether acupuncture is also needed.

I am 45 and considered myself to be a runner until last year. I rolled my ankle 1 year ago while running at dusk. Apparently nothing was broken.( besides tearing ligaments etc. My foot showed an enormous amount of bruising. MRI showed I had suffered an injury to the Talar Dome. Now a year later I have pain that is burning in the left arch close to the Navicluar -n spot.

I massaged it last night and now I can hardly walk on it and it burns while sitting. I had a bone scan and it didn't show any hotspots in that area. I read that the Navicular doesn't have much blood supply – so would it take up much of the dye? Any way I have gone through months where I can cope and some days hardly know I had a problem ,to days like today where there is a return of the burning pain with no reason really.

Its not painful in the morning but can get worse during the day .

I wonder if I have nerve entrapment in the fascia near the Navicular and the deep tissue massage I performed has stirred it up?

Worst thing about this accident is that the surgeon said no more running ,otherwise I could get arthritis . Yet the pain doesn't come from the ankle where the Talar injury is. Could I have an undiagnosed fracture?

May be time for more investigation. I would love to run agai. It's how I defined my life.

Hi,I misplaced my footing whilst competing in a half marathon a few months ago. Since then I've had a stinging sensation on inside of my left foot near my heel. I have seen a doctor and sports massage therapist. The diagnosis has been PF. However I'm not convinced as the PF is subsiding but I am still left with the stinging sensation. The best way to describe the pain is the stinging sensation you get when you are injected with a hypodermic needle.

Thank you for your article, however, I am still none the wiser as to what my problem may be. It started several months ago and stopped for about a month (after electro-acupuncture stimulation: 3 treatments of 3/4 hour) before restarting about 3 weeks ago. The problem is R heel pain that wakes me up every night between 3 and 4 a.m. I lie in bed rolling my foot and tensing my leg by 'pulling' my R foot toward the knee causing a stretch in my calf muscle. Often when stepping out of bed, the first few steps are excrutiating and only a few minutes walking around brings relief. During the day, the pain is not there, but the heel/foot does not feel 'right'. There is a mild discomfort and the heel feels slightly numb.

Any clarification on possible cause and relief/ cure would be much appreciated.

I really appreciate your article although my situation doesn't fit into any of the scenarios. 6 weeks ago, I missed a step coming down stairs at night and landed hard on the edge of the stairs (hard granite) with no shoes on. The pain is in the rear of the arch of my left foot. At first it was extreme and improved during the first week and has remained mild ever since. When I don't wear shoes, I have no pain during walking, except in the morning when it last for about ~ 10 minutes. With shoes I have mild pain during walking which is my real problem. I have no pain at rest with or without shoes. Can use please offer a treatment I can do on my own to try and improve the situation or do I need to see a doctor?

I would consult with an experienced physical therapist – one who has experience in both gait mechanics and manual therapy. They will want to address and treat all possible factors, including soft tissue, joint stiffness/pathology and how your gait might've changed as a result of the injury.

I'm so happy to have found this article! I've been having terrible heal pain that is getting worse the more I run. I'm going to (begrudgingly) take a week off and try these treatments, and see if it improves.

David – Have you gotten any more information? I am 49 yo male. I have been running since 1997 with over 35 marathons and several ultras. I had typical PF many years ago and successfully treated with rest and orthotics. I have been struggling for 2 1/2 years with "PF" pain again. However, this pain is at the very back of my right heel and localized to one spot. It hurts when I plant my foot and when I press on it. I have been to three podiatrists, three PT's, and to a chiropractor. I have tried complete rest, extensive stretching and strengthening, new orthotics (newly identified leg length discrepancy – so 1/4 lift added to non-affected side orthotic), cortisone injections (after 2 years of trying to avoid it), shockwave therapy, acupuncture with e-stim. X-rays have all been negative. I plan to have MRI next. Nothing has helped. I finally cut a horseshoe shaped notch out of my orthotic making the most posterior portion completely open. My idea was that possibly it's nerve related and this could take the pressure off of the nerve. Amazingly this has helped keep the pain at bay (not completely gone). Not sure why the pain and hoping the MRI will show what's going on.

I have been having pain in both my heals now for months, I walk twice every day as I have dogs and they need to go out, I also run, but I have had to stop this as the pain is unbearable. Even touching my heals with a finger causes pain. I have been to phisio but they cant help. I am really stuck for ideas of what this could be , any ideas?

Walk gait: it is shocking how many people are "pathologically" (e.g. pain-producing) inefficient walkers. How you walk (w/your dog or without) can play a huge role in the perpetuation of soft tissue and joint irritation of the feet. Once irritated, it doesn't take much inefficiency to keep the pain cycle going.

Joint mobility and nerve tension. How stiff is the mid- and rear-foot? Also, how is your back? I get about 1-2 patients per month whose foot pain is predominantly driven by referred lumbar/nerve pain (or at least it is a major magnifier).

Thank you so much for this info. In the last 2 years I have gone to 2 sports PT chiros, 2 podiatrists, cortizone shots, acupuncture, tons of reading, I have amassed a drawer full of massage tools. All to get rid of this pain and it just took some standing on my navicular to alleviate the pain haha, thank you!!

Thanks for the great article. I have been dealing with plantar fasciitis since March 2012. It had gotten so painful I gave up running all together Jan 2013. I have seen two podiatrists, one ortho foot /ankle doctor, and two physical therapists. I have had stiffness in my ankles for a year and a half now. Nothing helped until I read your article. I spent about 2-3 minute one evening doing the ankle dorsiflexion stretches for the talocrural joint and got immediate relief!!! It was like a miracle!!!! A year and a half of stiffness – gone. It has been three days since I did the stretch and still no stiffness. I feel like the fluid in the joint was finally released!

Now I have a new problem – went to a new physical therapist yesterday for an eval to see if there was a biomechanical reason for my PF. My symptoms of heal pain have greatly resolved and I want to start running again. He did a quick exam of me and said my right hip was higher than my left and I had no movement in my sacroiliac joint. This was why I had PF. He examined me with my shirt still on by placing his hands around my waist and by pressing on my lower back. Then while I laid on the table, he pressed up on my sacrum and down on my right and left ileum for about 20-30 minutes to “get movement” in the joint. He was happy when he saw my hips freely move up and down. Twelve hours later I was in severe pain, unable to sit, unable to lay flat. I am taking 800mg ibuprofen every six hours and am still in pain. Looking on the internet I see that this joint is really not supposed to move very much and usually these manipulations are done in people with back pain from traumas to the buttocks region. I have never had back pain until now. I am afraid I am now stuck with both PF and SIJ pain. Can please help me understand if there is any PT rationale for what he did? Is there a link between SIJ and PF?

A SIJ issue can cause PF by altering how the foot strikes (and pushes off) when walking. Your treatment was warranted, but likely too much (there is such a thing as too much of the right medicine). Contact your PT to discuss the outcome, and adjust your plan of care, accordingly.

Hi – I developed light heel pain about 3 months ago and carried on running for about 2 months making sure i iced regularly. I was running fine and thought that i was putting the issue behind me but after one week the pain become unbearable and i was not even able to properly flex my foot. It has been aobut 1 month since then and i initally tried to carry on running with no success. The main question i have is that i am struggling to diagnose the injury. I have seen a PT last week and he said that if i had plantar fasciitis than i would have experienced pain when he flexed my foot which i didnt. I have rested for one week and the pain does subside but can feel slight pain when my foot is flat on the ground and the heel is weight bearing. Any ideas what this could be and when i can start back running?

Oh I forgot to mention that the pain can be pretty much all over the heel. There is definitely pain towards to inner heel which is why i thuoght it was plantar fasciitis but there is also pain in the middle of the heel and towards the back.

Thanks for the post. It's impossible to diagnose what's going on with your foot, and this article highlights the multiple factors involved (muscle/tendon, joint, nerve, etc.).

*Assuming* that there is no pathology, and that it is a mere strain, I will commonly recommend shallow-water running for folks to re-introduce running stress with 50% less load. Try running for ten minutes in waist-deep water: real running, impacting the pool bottom.

However, I would continue to work with the PT and/or other practitioner so they can resolve any pathological issues, should they exist.

Joe, great article, one of the only i could find which talk about a diagnosis of heel pain other than plantar fasciitis. I told myself I would only look to the internet as a last resort and alas here I am. I'm still not sure though, the only thing that would make sense for me perhaps is the joint pain.

I started having heel pain about 3 years ago, at 23 years when I started working full time at my job in the summer. Eventually I was referred to a podiatrist who diagnosed me with plantar fasciitis. Went to therapy, have custom insoles, did the cortisone shots, compound creams, did the icing and calf/plantar stretches, nothing helped. So he suggested traditional surgery. I went to a 2nd podiatrist and went through the same thing, nothing worked and he recommended endoscopic surgery which I did. Took a month off work but it did not work at all, my pain is in fact worse than it was before the surgery. I still can't play basketball/run like I at least could attempt to before the surgery. And now he's recommending shockwave therapy which I'm not sure I should go through with.

My symptoms were also a bit different than most. I have no heel pain when I wake up in the morning or if I'm sitting/in bed. It was always after standing for a long time at work that caused the pain. Standing is the real killer, although walking hurts as well. I'm not able to quit my job or else that would at least solve the intense pain I experience.

I Have been having pain in my heels near the arch since nov 2012 I was told it was PA after anti inflammatory and 12 weeks time twice a week physio therapy with no success I went back to the doctor and demanded further testing only to find out the reason it is was not completely going away with the extensive therapy at home and at physio was because I have Rheumatoid Arthritis so I am now waiting to see a specialist

I just developed a sudden dull ache in my right heel about a day and a half ago and it will not go away. It is at the front of my heel bone right before my arch begins. It hasn't gotten worse, but it still concerns me a little bit. It first began on Wednesday night while I was sitting down (go figure). My heel just felt a little strange…I can't really describe it. But when I stood up and began walking around, it began aching. I ran Wednesday morning and had no problems with my heel. I've never had any issues with my feet at all before this. I did actually run yesterday (Thursday) morning as well. While I initially felt the dull, mild aching for a little bit, it eventually subsided completely during the rest of the run. It did return afterwards, though. Today, the situation still remains the same. It has not worsened, but there is still just a little bit of a nagging ache when I walk and when I apply pressure with my fingers. Does anyone have an idea of what this might be? Thanks in advance!

I have had chronic pain in my heels for years now. The longer I stand on them the more painful they become. Eventually they become so painful I have moments where it feels like someone is stabbing a needle into my heel. Orthotics have helped but not fixed the problem. I also get inflammation and use ice packs. Xrays do not show anything. My solution to the problem has simply been to not use my feet! Barefoot I can stand for 10-30min. With Orthotics 2-3hrs depending how much I move around. I know there is no solution but at least I feel a bit better being able to tell my problem. The worst problem is that there is no visible sign of a problem and no diagnosis so most people don’t believe me.

i fell from about roof height and put all the pressure on my heels. 1 week later i could not sleep on my back because my heels touching the mattress was too painful. i got xrays at the hospital. The doctor told me i had severe heel bruising and would get better in around 3 months. during the next 5 months i had to walk on my toes because my heels were too painful.. A YEAR LATER i could walk better but not normally, i was putting weight onto other parts of my feet. My heels feel like they are made out of glass or something like that. IT HAS BEEN 2 AND A HALF YEARS NOW. i have worked part time during this, so i have had plenty of time to rest. but this year i did a full time week and had to walk around everyday or just be standing. The pain got even worse. it went from being painful to unbearable. it feels like my feet are burning all the time. while my heels are touching nothing its quite comfortable. resting on my bed gets uncomfortable while my heels are touching the mattress. Walking around drains my energy quickly (because its painful) and the pain keeps increasing while im standing. theres been days that iv had to sit down on the ground because i cant take the pain any more. after resting for about an hour the burning sensation will go down but my feet feel uncomfortable. i went to a FOOT MECHANIC, he said that iv been walking wrong this whole time and i need to learn to walk again. he can make me a sole for my shoe that would help me put pressure on the right places of my feet while i walk. Other then that he said he doesn't know what the problem is. Should i get the sole ? its expensive ! and even just wearing shoes is uncomfortable because they are tight around my feet and it starts to hurt.
Yesterday i went to a FOOT SPECIALIST. i told him my whole story and straight away he said he cant help because it sounds like a CHRONIC PAIN problem. He said thers nothing wrong with the structure of my feet. He is sending me to a CHRONIC PAIN DOCTOR. He did not ask me any questions. (was expecting some help) Is there anything else i can do ? would an MRI help ? im 24 years old.. thanks for reading.

Pain – especially *trauma* is a "soup of many ingredients". When you have trauma like that, you not only stress bone, muscle, tendon, and ligament, but joint surfaces (cartilage).

And nerves.

My impression – based on your symptoms – is that you may have some nerve irritation, entrapment, or "damage" (scary word, but nerves WILL heal of treated correctly). The trauma of your incident is MORE than enough to cause nerve irritation that – unless treated – will not go away.

I strong consider you see a physical therapist with advance manual therapy certification:

I had an MRI done and it shows a muscle cyst (10*20*20mm) below the felxor hallucis longus that occupies the cranial part of the musculus quadratus plantae, protruding into the lateral part of calcaneous and based on the report it is possible that it presses on the areas where the plantar nerve passes. When receiving this report I was delighted and though that finally the cause was discovered and by removing the cyst I can go back dancing and live an active life again. Yet the orthopedic surgeon I went to see is not keen to put me in surgery and said that I'd be better off with conservative treatment. Now I wonder if I failed to improve as much during the past 4-5 years as to be able to resume running/dancing can he be right? Or does a surgery of removing the cyst impose so much risk of hurting the surrounding tissues/nerves?
Perhaps I shoud go and seek a second opinion.
What do you think?

I tested my symptoms based on the criteria in your article, and I do not get the morning stiffness at all (so I guess my problem is not PF also because the stretches never helped), I notice some immobility and pain when doing the wall ankle strech (joints implicated?), when it is bad then I have a dull pain in the heel that sometimes gives a burning sensation too, and I tend to have pain through the arch with stiffness in the calf despite appropriate warm-up before and stretching after exercise (nerve is pressed?). I wear arch support since that injury but to be honest i think it makes my feet pronate even more than natural because the medial part is pretty high and the lateral shows no elevation at all. I really don't know what to do next and how to get my foot health back to be able to dance again.
Thanks everyone for any ideas or advice!
Aniko

Dear Joe,
Just came across your article and have been reading some of the posts too. Great summary and really helpful for those stuggling with heel pain that doesn't seem to subside.
I'm however still rather clueless regarding what would work for me.
I was a ballroom dancer and some years ago I had an injury, dancing in high heels and all of a sudden I felt a sharp pain and couldn't stand on my foot anymore. It swell, got red, and I was in sharp pain for about 3 weeks. I went to see orthopedist specialists who sent me away with the diagnosis of plantar fascitis, recommended rest, icing, etc. It eventually did become better, I can live a normal life, have limitations though in doing sports. I can hike in well supporting boots for example but cannot run and could take up ballroom dancing again. If I give running or dancing a try, even if in falt shoes or with very small heel the pain comes back. It does not hurt when doing the actual exercise but it comes usually the day after or past two days and lasts for 1-2 weeks.

I was wondering if you could help/advise. I am getting a sharp needle type pain on the outside of my right heel about 1/2 inch from where the heel meets the floor (towards the rear), I get it when I straighten and raise my leg (approx 30-40 degrees) and pull my toes toward my body – it feels like something is tearing just underneath the skin.
If I continue the pain subsides but this would leave the area feeling slightly numb and a dull ache for the next hour or so.
I get the same steeling but a lot milder in the left foot.
The sypmtoms started approx six weeks ago and is slowly getting worse.

I had a discectomy on L5/S1 in march 2013 so my initial thought was nerve tension, but the fact it is in both feet made me think twice.

I have tried the nerve tension excercise (slump test) and lifting my head back or slumped forward has no effect at all on the pain. I wondered if its possible that a nerve is pinched in the foot?
I can pull my toes up with a bent leg with no pain or unusual feeling at all but as soon as the leg gets nearly straight it starts.

I brought a new pair of shoes approx two week weeks before I noticed anything – could this be the cause? As its the only thing I can think of that could effect both feet.

Someone recommended deep tissue massage on my legs as I do have quite tight hamstrings/calves/Achilles!

Have you ever come across this before? Any help from anyone would be great as I have been given conflicting treatment advice and don't want to do anything to make this worse.

Hi joe
good article covered almost everything. But what I m suffering is pain in heel only if I stand for say 10 minutes which onsets from 5 minutes ..pain depletes if I rest.no pain when I wake in morning ..but the pain gradually builds up during the day, im nt an athlete

I've had Plantar Fasciitis in both feet and I couldn’t seem to find any relief from the pain. I took 5 shockwave therapies till now and have been stretching exercising and putting night split, ice rolling, shoes. And I couldn’t even walk without pain. I’ve been using MEDICOVI Twin-heels ( http://www.medicovi.com ) orthopedic insoles. New technology has opened up possibilities for this effective form of orthopaedic relief that combines movement with dynamic pressure relief. This new technology counteracts the negative effects that our modern way of life has on our bodies, while providing instant relief for heel pain and foot pain caused by heel spur and plantar fasciitis. One of the biggest problems of our modern lifestyles is a lack of movement of the foot and the motor system, and it is a key reason that doctors advise patients to exercise and move more frequently. I’ve been using theese for months now and I’ve just bought my second pair. I’ve always suffered from pain in my feet, especially around the heels. Since owning these my life has literally changed. I can now walk & run with a smile on face. Can’t recommend them highly enough.

Thanks for all the information here. The bone joint pictures are really helpful. I've also heard about treating foot pain with infrared heat with something like one of these. Do you think that would help with a sore heal?